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CMS Proposed Rule for CY 2025 Medicare Physician Fee Schedule

by Jasmine Pennic 07/15/2024 Leave a Comment

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CMS Finalizes New Interoperability and Prior Authorization Rule

– The Centers for Medicare & Medicaid Services (CMS) released a proposed rule outlining changes to Medicare payments under the Physician Fee Schedule (PFS) for services furnished and other Medicare Part B issues on or after January 1, 2025. 

– The calendar year (CY) 2025 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a more equitable healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation for all Medicare beneficiaries.

Here’s a summary of the key proposals:

Payment and Coding

  • Reduced Payment Rates: Average payment rates under the PFS are expected to decrease by 2.93% due to statutory factors.
  • Conversion Factor Decrease: The PFS conversion factor, used to calculate payment rates, is proposed to decrease to $32.36 from $33.29.
  • Advanced Primary Care Management (APCM): New codes and payment for a bundled service reflecting essential elements of advanced primary care like care management and communication technology.
  • Cardiovascular Risk Assessment and Management: New codes and payment for assessing ASCVD risk and for risk management services.
  • Strategies for Improving Global Surgery Payment Accuracy: Broader use of transfer-of-care modifiers for global surgical packages and a new add-on code for post-operative care services.
  • Behavioral Health Services: Separate coding and payment for safety planning interventions for patients in crisis, payment for digital mental health treatment devices, and new G-codes for interprofessional consultation.
  • Opioid Treatment Programs (OTPs): Increased payment for intake activities to include social determinants of health assessments, establishment of payment for new opioid agonist and antagonist medications, and clarification of billing requirements.
  • Hospital Inpatient/Observation E/M Add-on for Infectious Diseases: New add-on code for the complexity of infectious disease care by specialists.
  • Supervision Policy for Physical Therapists (PTs) and Occupational Therapists (OTs): Allowing general supervision of PTAs and OTAs by PTs and OTs in private practice.
  • Certification of Therapy Plans: Reduced burden for therapists by allowing exceptions to physician/NPP signature on initial certifications in certain cases.
  • Dental and Oral Health Services: Payment for dental services linked to covered services for End-Stage Renal Disease (ESRD) and proposing additional linked services for specific conditions.

Telehealth Services

  • Addition of services to the Medicare Telehealth Services List, including demonstration prior to home INR monitoring and caregiver training.
  • Continued suspension of frequency limitations for certain telehealth services.
  • Allowing audio-only communication for home telehealth visits when video is not possible.
  • Permitting distant site physicians to use their enrolled practice location address when providing telehealth from home (through 2025).
  • Permanent adoption of a definition allowing real-time audio-visual virtual direct supervision for certain services.
  • Continued virtual presence for teaching physicians in all teaching settings for services furnished involving residents (through 2025).

Other Proposals

  • Request for Information (RFI) on an ambulatory specialty care model leveraging Merit-based Incentive Payment System (MIPS) Value Pathways.
  • RFI on existing Community Health Integration Services, Social Determinants of Health Risk Assessment, and Principal Illness Navigation Services.
  • RFI on additional payment policies recognizing advanced primary care services.
  • Requiring manufacturers of certain single-dose drugs to provide refunds for discarded amounts.
  • Approach to payment limit calculations when negative or zero drug pricing data is reported.
  • Clarification on payment methodologies for radiopharmaceuticals in physician offices.
  • Modification of regulations to include certain compounded immunosuppressive drugs in the immunosuppressive drug benefit.
  • Update to clarify clotting factor furnishing fees for self-administered products.

Next Steps

The public can comment on the proposed rule before it is finalized. The final rule will be published later in 2024.

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